PROFFESOR.S.FLORET
NORMAL STRUCTURE
DEVELOPMENTAL/CONGENITAL
• Polythelia
• Polymastia
• Athelia
• Amastia
‐ poland syndrome
• Nipple inversion
• Nipple retraction
• NON‐BREAST DISORDERS
• Tietze disease
• Sebaceous cyst & other skin disorders.
• Monder’s disease
BENIGN DISEASE OF BREAST
• Fibroadenoma
• Fibroadenosis‐ ANDI
• Duct ectasia
• Periductal papilloma
• Infective conditions‐ Mastitis
‐ Breast abscess
‐ Antibioma
‐ Retromammary abscess
Trauma – fat necrosis.
NIPPLE INVERSION
• Congenital abnormality
• 20% of women
• Bilateral
• Creates problem during breast feeding
• Cosmetic surgery does not yield normal
protuberant nipple.
NIPPLE INVERSION
NIPPLE RETRACTION
• Nipple retraction is a secondary phenomenon
due to
• Duct ectasia‐ bilateral nipple retarction.
• Past surgery
• Carcinoma‐ short history,unilateral,palpable
mass.
NIPPLE RETRACTION
ABERRATIONS OF NORMAL DEVELOPMENT AND
INVOLUTION (ANDI)
• Breast : Physiological dynamic structure.
‐ changes seen throught the life.
• They are
‐ developmental & involutional
‐ cyclical & associated with pregnancy
and lactation.
• The above changes are described under ANDI.
PATHOLOGY
• The five basic pathological features are:
• Cyst formation
• Adenosis:increase in glandular issue
• Fibrosis
• Epitheliosis:proliferation of epithelium lining
the ducts & acini.
• Papillomatosis:formation of papillomas due to
extensive epithelial hyperplasia.
ANDI & CARCINOMA
• NO RISK:
• Mild hyperplasia
• Duct ectasia.
• SLIGHT INCREASED RISK(1.5‐2TIMES):
• Moderate hyperplasia
• Papilloma with fibrovascular core.
• MODERATE RISK(4‐5times):
• Atypical ductal hyperplasia
• Atypical lobular hyperplasia
Progression to Breast Cancer
CLINICAL FEATURES
• ANDI presents in various forms including:
• Discrete breast lump
• Lumpy breast
• Nipple discharge
• Breast pain(cyclical,noncyclical)
• Mastalgia affects upto 70% of women at some
point in their life.
• Two‐third of patients affected have cyclical
mastalgia & one‐third have non‐cyclical
mastalgia.
INVESTIGATIONS
• FNAC
• Biopsy
• Mammography
• ultrasound
TREATMENT
• Reassurance itself may suffice for those with lumpy breasts.
• CYCLICAL MASTALGIA : due to hyperestrogenism.
abnormal prolactin secretion also been
implicated.
• Initial treatment: assurance.
evening primrose oil(gammalinolenic acid).
• Treatment of choice:Danazol
Bromocriptine
Tamoxifen(promising drug of choice)
• NON‐CYCLICAL MASTALGIA: difficult to treat.
• Search should be made for musculoskeletal cause of pain.
• Excising a painful trigger spot in breast causes occasional relief.
FIBROADENOMA
• Benign tumor of breast lobule.
• Composed of stromal & epithelial elements.
• AETIOLOGY:
• Occurs in developmental stage of breast.
• Due to oestrogen sensitivity.
FIBROADENOMA
PATHOLOGY
• Gross examination: tumor is,
‐ 2 to 3cm in size.
‐ sharp boundaries
‐ cut surface is glistening
white.
• Microscopically,there are two types:
• Intracanalicular type: stroma compresses the
ducts into slit‐like structures.
• Pericanalicular type: stroma just surrounds the
ducts without compressing them.
FIBROADENOMA
FIBROADENOMA‐ cut‐
section
bulging,
whirled like
cut‐cabbage.
• Fibroadenoma is not a premalignant
condition.
• Co‐existentence in cancer pts is most often a
lobular carcinoma in situ.
• fibroadenoma – bimodal age of occurrence.
• Younger pts – juvenile fibroadenoma.
• fibroadenoma>5cm – Giant fibroadenoma –
no malignant potential.
GIANT FIBROADENOMA‐>5cm
CLINICAL FEATURES
• HARD FIBROADENOMA:
• Younger age.
• No malignant potential
• SOFT FIBROADENOMA:
• Older age
• Has malignant potential.
• DIAGNOSIS: FNAC
• TREATMENT:
• Women <25yrs – not removed.
• Older women – Excisional biopsy.
• Local recurrence is rare.
• Giant fibroadenoma – enucleation of
complete tumor by cosmetic incision.
PHYLLODES TUMOR
• Previously termed as cystosarcoma phyllodes.
• PATHOLOGY: The tumor is
• Circumscribed
• Irregular surface with projections(leaf‐like) hence called as phyllodes.
• Soft in consistency
• Cut surface – brown color,with areas of hemorrhage,necrosis,cystic
change.
• Histologically: epithelial & fibrous elements present.
• 3 GRADINGS:
• BENIGN.
• INTERMEDIATE.
• MALIGNANT.
• Malignant lesions have evidence of sarcoma which is usually liposarcoma
or rhabdomyosarcoma.
PHYLLODES TUMOR
• CLINICAL FEATURES:
• Women between 30 – 50yrs.
• Tumor – grows‐ large size –usually mobile.
• Skin – not infiltrated but stretched out,reddened
with ulceration due to pressure necrosis.
• TREATMENT:
• Excision.
• Large tumors – simple mastectomy.
• Local recurrence‐ upto 25% ‐ wide local excision.
BREAST CYST
• Formed due to cystic lobular involution with
formation of lobular microcysts which
coalesce to form macrocyst.
• Predisposing factor – obstruction to lobular
outflow.
• It is a type of ANDI and associated with
hyperestrogenism.
BREAST CYST
CYST ‐ 2 TYPES
• SIMPLE CYST: simple cuboidal epithelium
• Single
• Do not recur.
• No association with cancer.
• APOCRINE CYST: apocrine epithelium
• Tendency to recur.
• Association with cancer.
• CLINICAL FEATURES:age group of 40‐50 yrs.
• Pain – occasionally present.
• Solitary & large at time of presentation.
• Examination: cysts – smooth surfaced & dark in
color – blue domed cysts.
• DIAGNOSIS:Aspiration of cyst fluid‐ pale yellow to
black color.
• Mammography & ultrasound to exclude
malignancy.
• TREATMENT:
• Aspiration of cyst till it is impalpable.
• Residual mass after aspiration is an indication
for FNAC or biopsy.
• Indications for surgical excision are:
• Blood stained aspirate‐ indicator of intracystic
carcinoma.
• Cyst recurrence after repeated aspiration.
GALACTOCOELE
• Milk filled cyst – either occurs at
time of cessation of lactation or
frequency of lactation is less.
• Occurs due to obstruction of major lactiferous
duct by inspissated milk.
• TREATMENT:
• Needle aspiration
• Surgery – when cyst cannot be aspirated or gets
infected.
GALACTOCOELE
DUCT PAPILLOMA
Single.
Sub‐areolar.
Less malignant potential.
• INVESTIGATION:
• FNAC done for lump.
• Cytology of bloody discharge
• Mammagraphy
• Ductography identifies offending duct‐insensitive.
• TREATMENT:
• Surgical excision.
• Offending duct probed‐ circumareolar incision
made‐ probe identified‐ duct excision‐ sent for
histopathology.
DUCT ECTASIA
• Type of ANDI occurs due to ductal involution.
• Perimenopausal age group.
• Dilation of large periareolar ducts.
• PATHOLOGY:
• Ducts filled with periductal infiltration of thick green or
creamy secretion with periductal infiltration of chronic
inflammatory cells.
• Discharge: bilateral‐ multifocal‐ thick – varying colors.
• Intraductal ulceration‐ bloody,unifocal discharge from
nipple.
• Periductal ulceration‐ mass below nipple.
DUCT ECTASIA
• The exact mechanism of ductal dilatation is not known
but possibly due to:
• Primary periareolar inflammation leading to ductal
dilation.
• Obstruction of the ducts with dilation.
• Management:Reassurance & antibiotics for
suppuration.
• Needle aspiration
• Incision & drainage
• Repeated episode of infection – total duct excision
under antibiotic cover.
TRAUMATIC FAT NECROSIS
• Not a premalignant condition.
• Preceded by history of trauma to the breast.
• Histology :granular histiocytes surrounding
cyst containing free lipid.
• Importance lies in differentiating it from ca
breast.
MONDOR’S DISEASE
• Is characterized by thrombophlebitis of the superficial veins
adjacent to the breast.
• Precipitated by surgical procedures,infection, repetitive
movements of upper extremity.
• Lateral thoracic vein & thoracoepigastric veins are most commonly
affected.
• Benign
• Painful
• Examination: tender firm cords in the direction of veins.
• DIAGNOSIS:
• Biopsy – if there is mass adjacent to affected veins.
• TREATMENT:Analgesic & local hot compresses.
• Resolution within 2‐6weeks
• Refractory cases – ligature above & below the site of involvement.
MONDOR’S DISEASE
BREAST ABSCESS
• Two types:
• Lactational breast abscess
• Non‐Lactational breast abscess
LACTATIONAL BREAST ABSCESS
• Occurs either at commencement of feeding orduring the period of
weaning,when breast is engorged due to residual breast milk.
• Cracked nipple – entry of infective organism‐ usually staphylococcus
aureus.
• Presents – breast discomfort followed by pain & fever.
• Signs of acute inflammation – if untreated – abscess formation.
• On aspiration‐ pus not found‐ systemic
antibiotics(flucloxacillin,cloxacillin) for 10 days needed.
• Tetracycline,chloramphenicol & ciprofloxacin‐ contraindicated.
• If pus is aspirated‐ incision & drainage done.
• Suppression of lactation required – bromocriptine 2.5mg/d for
14days.
PREDISPOSING FACTOR‐ Cracked nipple.
BREAST ABSCESS
BREAST ABSCESS
BREAST ABSCESS
INCISION & DRAINAGE
• Done when pt does not respond to 2 to 3days
of antibiotics.
• Incision made at site of maximum tenderness
– radial or transverse.
• Counterdrainage advised when abscess is
deep.
NON‐LACTATIONAL BREAST ABSCESS
• Complication of duct ectasia‐ tends to recur.
• Seen in periareolar region.
• Bacteroides, anerobic streptococci &
enterococci. Administration of cloxacillin
&metronidazole.
• Incision & drainage – avoided if possible.
NIPPLE DISCHARGE
• Suspicion of breast carcinoma which is rarely associated.
• May or may not be associated with lump.
• CAUSES OF BREAST DISCHARGE:
• PHYSIOLOGICAL:‐ during pregnancy‐ reassured.
• DUCT ECTASIA:‐ discharge‐ multifocal‐bilateral‐ varying colors.
• DUCT PAPILLOMA:‐serous,serosanguinous or frankly blood‐stained.
• GALACTORRHOEA:‐milky discharge‐
hyperprolactinaemia,menarche,menopause,drugs(haloperidol,met
oclopramide,methyldopa).
• CARCINOMA:‐usually from single duct‐ serous or blood‐stained.
• CYSTS
• IDIOPATHIC:‐10% cases
TYPES OF NIPPLE DISCHARGE
• SEROUS DISCHARGE:
• Duct papilloma
• Mammary dysplasia
• BLACK/GREEN DISCHARGE(altered blood):
• Duct ectasia
• BLOOD STAINED DISCHARGE:
• Duct papilloma
• Duct carcinoma
• Duct ectasia
• MILKY DISCHARGE:
• Galactorrhoea
• Endocrine disorders(pituitary adenoma,cushing’s
syndrome,TCA’s,verapamil).
INVESTIGATIONS
• Mammography
• Ductography
• Cytology of discharge
TREATMENT OF NIPPLE DISCHARGE
• 1.Nipple discharge with lump: remove the lump.
• 2. Nipple discharge without lump:
• Discharge from one duct only‐ perform
microdochectomy(remove affected duct by passing a
probe into it).
• Discharge from more than one duct‐ check the
discharge for haemoglobin
‐ if positive in women over 40 yrs‐ cone excision of
major ducts.
‐ if negative or positive in pts less than 40yrs‐
policy is to observe.
GYNAECOMASTIA
• Presence of female type of mammary gland in
the male.
‐Not a disease.
‐Enlargement of male breast is
common.
GYNAECOMASTIA
• PHYSIOLOGIC GYNAECOMASTIA: during three phases
of life.
NEONATAL PERIOD – action of placental estrogen
on neonatal breast parenchyma.
ADOLESCENCE PERIOD‐ Excess of estrogen with
relation to testosterone.
SENESENCE PERIOD‐ increase of estrogen
relation to testosterone.
PATHOPHYSIOLOGY
• 1.Estrogen excess state
• 2.Androgen deficient state
• 3.Drug related
• 4.Systemic disease with idiopathic
mechanism.
PATHOLOGY
• There is combined increase in glandular & stromal element.
• There is regular distribution of each element throught
enlarged breast.
• The ductal structure of the male breast enlarge,elongate &
branch out with ensheathing connective tissue.
• ADOLESCENCE GYNAECOMASTIA:
• Often unilateral.
• Typically between age of 12 to 15yrs.
• SENESCENT GYNAECOMASTIA:
• Usually bilateral.
• Gynaecomastia do not predispose to cancer.
• By contrast,
• Hypoandrogenic state of
‐ primary testicular failure.
‐ klinfelter’s syndrome
Is associated with high risk of breast
cancer.
CLINICAL FEATURES
• Dominant non‐tender mass.
• Local area of firmness
• Irregularity
• Asymmetric
CLINICAL CLASSIFICATION
I. Mild engorgement withOUT skin reduntancy
II. Moderate engorgement withOUT skin
reduntancy
III. Moderate engorgement with skin
reduntancy
IV. Marked engorgement with skin reduntancy
& ptosis similar to female breast.
INVESTIGATION
• USG
• Mammography
• To differentiate‐ indistinguishable or ill‐defined fatty
tissue from male breast lesion& soft tissue structure.
• TREATMENT: Treat the cause.
• Due to drugs‐ stop the drugs.
• Syndromes‐ treat the primary cause.
• Idiopathic‐ physiological‐ assurance below the age of
18.
• Bigger size‐ surgery‐ websters